The Checklist Manifesto: Britain’s adoption of a Safer Surgery Checklist one year on
Guest lecturer: Dr Atul Gawande
Last week I went to hear a few people talk about patient safety, in reference to the newly mandated surgical checklist - the keynote speaker was Atul Gawande who I first heard of in July last year when I heard a rebroadcast of his interview, by Steve Mirsky for the Scientific American podcast, Science Talk, speaking about his (then) most recent book "Better".
This was the order of play
17.45: Arrivals and refreshments
18.30: Welcome address: Lord Patel, Chairman, National Patient Safety Agency
18.35: Address: Sir Liam Donaldson, Chief Medical Officer for England, Department of Health
18.45: Perspectives from the UK: Dr Suzette Woodward, Dr Sukhmeet Panesar, National Patient Safety Agency
18.55: Guest lecture: Dr Atul Gawande
19.45: Response: Mr John Black, President, Royal College of Surgeons
19.55: Q and A: Dr Suzette Woodward
20.15: Vote of thanks and close: Professor James Reason
Lord Naren Patel is the Chair of the National Patient Safety Association (NPSA) among many other things (he also chaired a debate in the House of Lords in 2007 on stem cell therapy which is worth a read).
Liam Donaldson mentioned a document he wrote in 2000 called "The organisation with a memory". It's about systems failures in healthcare (rather than just blaming the nearest person who may have made a mistake) and draws an analogy with the airline industry which has adopted a different cultural approach to dealing with error.
Next Dr Suzette Woodward talked about the work being done with http://www.patientsafetyfirst.nhs.uk - they do a lot of interesting engagement work with doctors and patients. Dr Sukhmeet Panesar spoke about his work with 'Project SAVED' in encouraging people to get involved with the surgical checklist and how gradual cultural changes might happen with engagement.
I made quite a few notes during Atul's talk - they might not all make sense... my notes are a few days old, scrawled in pencil in my notebook and disjointed because sometimes I'll just sit and listen without writing. Don't rely on this as an accurate representation of the event :)
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Atul Gawande (AG) paid tribute to James Reason (who was sitting in the first row with his family) and mentioned that he'd read his work and had subsequently met him / become friends. He highlighted his work with WHO in making patient safety a priority.
'Complexity is the reason healthcare is failing' - failures may be to do with ignorance or ineptitude (otherwise known as 'difficulties with execution' which got a laugh from the audience). Ineptitude arises where the knowledge about how to do something exists but is misapplied (the field of human factors research categorises several ways in which errors can be considered) .
AG said that we had been fooled by penicillin, which had led to the belief that the treatment of diseases was straightforward and that research followed a neat path of exploration and then execution of the results.
He gave a very nice example of systems versus individual components - medicine likes the best components (the newest machine that goes 'bing' for example) but it forgets the system, and optimising parts is not a good route to system excellence. A car with a Ferrari engine and a Volvo body isn't a great car, but a bit of a mess.
Boeing instituted a two minute, 19 item checklist for their airline folk, at which point I randomly added in my notes that it's not just about having a checklist but about the types of questions that are asked. Not quite sure why, it being that obvious ;)
The surgical safety checklist is a staged checklist (I think it has 'deliberate pauses' added in to make people think about something, I've not seen one up close but this makes me think of 'rests' as used in musical notation) so there is a column of things to think abou before induction of anaesthesia, before skin incision and before the patient leaves the operating room.
If your spleen is removed this makes you at risk for three bacterial infections and certain vaccines are required. AG mentioned one man who, for whatever reason, didn't get the necessary vaccine(s) as each member of the team thought another was dealing with this (I think this must have come out in an enquiry) and he ultimately lost his fingers and toes following a pneumococcal infection which he couldn't shake off (as I suppose one normally would if all was well with the immune system).
Then we had questions and answers from the audience, including from Paul Somerfield /Summerfield from the RSM who asked about adherence to protocol and teamwork, Geraint Lewis from Nuffield and James whose last name I didn't catch from UCL Partners asking if patients should be asking their surgeons 'are you using the checklist?'
Adherence
The importance of teamwork and adherence to protocol was illustrated by the landing of the aircraft on the Hudson river. The pilot and copilot hadn't flown with one another before but during the pre-flight checks they would have introduced themselves and gone through a set of required checks and brief discussions. AG mentioned that they were also both very experienced, flying for a couple of decades without an engine going out on them, and they'd probably expect to retire without experiencing it. However they still followed protocol and ran through their checks. Apparently the transcript of the flight landing is notable for its 'quietness' - there's not much discussion beyond confirming a few things and no panicking because they knew what to do, however the captain had about three minutes to decide where to park the aircraft.
Patients asking
Some, though not all, patients may feel empowered to ask doctors or nurses to wash their hands, particularly if signs are displayed encouraging them to do so. There's been some success in pneumonia treatment by involving the patients' families - it's important for the top of the bed to be raised to help clear fluids but sometimes this step might be forgotten. Asking the family to watch out and ensure that the bed is up involves them in caring for the patient.
AG said that one US state had proposed that it would be illegal to do surgery without the checklist (forget which one but I think it might have been Massachusetts) but he felt it was more important to get the support of early adopters to increase the value of the checklist.
Someone else spoke at this point and I'm afraid I didn't write his name down (I'm pretty sure it wasn't James Reason, as listed, but I might be wrong).
This speaker mentioned debriefing as an important factor as well as the checklist briefing and gave the example of construction work which can involve 60 agencies supplying 500 staff who don't all know what their colleagues are up to. Buildings rarely fall down and the success of the end product is perhaps down to the processes that the people in charge of the project use - briefing and debriefing and then letting people get on with it (once they've signed off on a piece of work). The checklist is part of a process.
He also made the point that the checklist is good for surgeons too - if someone has inadvertently taken out the wrong kidney they're 'not the same again'. Finally he mentioned that even pilots can get it wrong - a flight had to land too early because the pilot calculated the fuel needed in kilograms but signed for it in pounds.
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I recently started working on a project at UCL which looks at a range of factors, including human factors, involved in errors when using interactive medical devices - so this talk was particularly helpful. I've also been reading James Reason's paper 'Safety in the operating theatre - Part 2: human error and organisational failure' (abstract).
Anyway hope the above makes sense.
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Follow-up thoughts (30 June 2011): I wrote this in February 2010 when I'd literally just joined the new CHI+MED project, working two days a week as the Public Engagement Co-ordinator. I'd probably had fewer than five days in the office because the snow was particularly grim in January, but I'd just about picked up that James Reason's work was extremely important. As mentioned in the piece I'd heard of Atul Gawande through a science podcast but I don't think it had even occurred to me to invite my new colleagues.
Moving from a biochemistry / neuroscience and latterly endocrinology background (well, I still do this) to the world of human factors was a bit of a steep learning curve - I'm still learning of course. But having re-read this blog post, I do think I've got a better and more cohesive understanding of the talk that I probably didn't have at the time - just because I've read a bit more of some of the background papers.
The research that CHI+MED is doing is looking at finding ways of making interactive medical devices (such as chemotherapy infusion pumps) safer. It's a large multidisciplinary project (four universities and two hospitals) blending knowledge and skills from psychology, computer science and maths to learn about how errors are made, and how they can be prevented or mitigated by being 'designed out'. We're funded for six years by the EPSRC (£5.7m).
Everyone on the project is working with different groups of people (stakeholder engagement) - this is because in order to transform the way in which medical devices are designed, regulated, purchased and used we need to be working with, and understand the needs of, the people who are doing the designing and the using and everything in between. So the engagement informs our work, but we also want to tell people about us and our work too of course.
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